Surgical stress response and the potential role of preoperative glucocorticoids on post-anesthesia care unit recovery

Steinthorsdottir, Kristin Julia; Kehlet, Henrik; Aasvang, Eske Kvanner

doi:10.23736/s0375-9393.17.11878-x

Cited by 33 publications

(13 citation statements)

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“…The finding also coincided with a statistically significant difference in CRP levels between the two patient groups in the subset undergoing major resections, supporting recent studies with significantly higher levels of CRP and IL‐6 in patients with postoperative delirium compared with controls, 27,28 supporting the systemic‐ and neuroinflammatory component in POD 30 . Although a correlation between peripheral‐ and central nervous inflammation and subsequent delirium has been suggested, 14,15 there is a gap in knowledge of the relative role of neuroinflammation, especially in relation to other suggested risk factors such as impaired perfusion, pain, sleep, opioids 31 calling for further studies, ideally including biomarkers for neuroinflammation. We did not find an increased incidence of complications leading up to POD to explain the observed difference between patients with and without POD.…”

Section: Discussionsupporting

confidence: 71%

“…Other (Open radiofrequency ablation/ Non-anatomically major) | 701 component in POD. 30 Although a correlation between peripheral-and central nervous inflammation and subsequent delirium has been suggested, 14,15 there is a gap in knowledge of the relative role of neuroinflammation, especially in relation to other suggested risk factors such as impaired perfusion, pain, sleep, opioids 31 calling for further studies, ideally including biomarkers for neuroinflammation. We did not find an increased incidence of complications leading up to POD to explain the observed difference between patients with and without POD.…”

Section: Discussionmentioning

confidence: 99%

“…11 The underlying pathophysiology for ED/POD is not yet clarified but suggested to be multifactorial, with increased risk from postoperative pain, poor sleep, opioid administration, 12 surgically induced inflammation, 13 and neuroinflammation. 14,15 To counter the detrimental effect of surgically induced inflammation and pain, pre-operative glucocorticoid administration has been used in different surgical settings 15 and has been shown to reduce postoperative nausea and vomiting (PONV) and pain. 16 Several studies have shown that the pre-operative administration of glucocorticoids reduces peripheral inflammatory markers in hepatic surgery.…”

Section: Introductionmentioning

confidence: 99%

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High‐dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double‐blinded randomized clinical trial substudy

Awada

Steinthorsdottir

Schultz

et al. 2022

Acta Anaesthesiol Scand

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Background: Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of preoperative high-versus low-dose glucocorticoid on the occurrence of ED and POD. Methods: This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward. Results: Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group. Conclusions:The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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High‐dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double‐blinded randomized clinical trial substudy

Awada

Steinthorsdottir

Schultz

et al. 2022

Acta Anaesthesiol Scand

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“…Postoperative manifestation of surgical stress such as pain, fatigue, wound drainage, and PONV–all of which hinders mobilization–are known factors that influence LOS [ 3 , 36 , 40 , 41 ]. Glucocorticoids have shown to be most powerful in reducing these inflammatory responses [ 42 ], and high-dose corticoids on a large scale have been reported with so far no safety issues [ 43 ]. However, neither corticoids [ 44 ] nor postoperative hemoglobin concentrations or opioid use [ 45 ] seem to correlate to orthostatic intolerance.…”

Section: Discussionmentioning

confidence: 99%

On the generalizability of same-day partial knee replacement surgery—A non-selective interventional study evaluating efficacy, patient satisfaction, and safety in a public hospital setting

Tveit

2021

PLoS ONE

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Purpose Programs referred to as Fast-Track/Rapid Recovery/Enhanced Recovery After Surgery have proven both effective and safe in joint replacement surgery, to the degree where same-day discharge (SDD) has been attempted in carefully selected cases at specialized outpatient units. Therefore, the primary aim of this study was to evaluate a same-day surgery protocol regarding safety using the minor partial knee replacement (PKR) procedure by non-selectively recruiting patients at a public hospital for one consecutive year. Methods 33 unselected PKR cases were included in this open clinical trial. The inclusion/exclusion criteria were solely based on logistics, as all the procedures were medial PKRs, designated the first morning slots, and performed by one single-surgeon. Strict postoperative criteria based on vital parameters, urinary function, bleeding, and mobilization had to be met before discharge was considered. SDD rate, patient satisfaction, number of outpatient visits, adverse events and readmissions within 90 days were evaluated. A predetermined subgroup analysis was also conducted where patients <80 yrs. and with an American Society of Anesthesiologists (ASA) classification <III was compared with those aged ≥80 yrs. and/or ASA class ≥III. Results 29 of 33 (88%) successfully achieved SDD. In a univariate comparison, 100% of the patients <80 yrs. and ASA class <III achieved SDD, whereas a corresponding 43% applied for those aged ≥80 yrs. and/or ASA class ≥III (p = 0.001). A 93% overall satisfaction rate was reached. Only 8% extra outpatient visits were required, all occurring within the first 2 weeks (well in line with routine practice.) One plausible transient ischemic attack and one readmission caused by a penetrating trauma not affecting the knee were identified, both of which happened 10 weeks after surgery. No adverse events or readmissions occurred within the first 48 hours of surgery. Conclusion When following strict criteria for discharge, same-day partial knee replacement surgery may be both feasible and safe, even without preselection of patients.

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“…A common risk for comorbid patient groups is in‐hospital haemodynamic deterioration, 1,2 where early recognition and treatment may be crucial in order to prevent further deterioration. Examples are chronic obstructive pulmonary disease (COPD) patients who have a high prevalence of comorbidities, 3 and surgical patients who have increased risk of multiple complications as a result of increased inflammation 4 or direct surgical complications such as bleeding, infection, and anastomotic leakage 5,6 . Abnormal vital signs are potential predictors of complications and mortality, thus, risk prediction and triage scoring systems, such as the early warning score (EWS), have been implemented as part of the clinical assessment 7,8 .…”

Section: Introductionmentioning

confidence: 99%

Continuous peripheral perfusion index in patients admitted to hospital wards – An observational study

Rasmussen

Aasvang

Haahr-Raunkjær

et al. 2020

Acta Anaesthesiol Scand

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Introduction: Risk patients admitted to hospital wards may quickly develop haemodynamic deterioration and early recognition has high priority to allow preventive intervention. The peripheral perfusion index (PPI) may be an indicator of circulatory distress by assessing peripheral perfusion non-invasively from photoplethysmography. We aimed to describe the characteristics of PPI in hospitalized patients since this is not well-studied. Materials and Methods:Patients admitted due to either acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major abdominal cancer surgery were included in this study. Patients were monitored continuously up to 96 hours with a pulse oximeter. Comparisons between median PPI each day, time of day and admission type were described with mean difference (MD) and were analysed using Wilcoxon rank sum test and related to morbidity and mortality.Results: PPI data from 291 patients were recorded for a total of 9279 hours. Median PPI fell from 1.4 (inter quartile range, IQR 0.9-2.3) on day 1 to 1.0 (IQR 0.6-1.6) on day 4. Significant differences occurred between PPI day vs evening (MD = 0.18, 95% CI 0.16-0.20, P = .028), day vs night (MD = 0.56, 95% CI 0.49-0.62, P < .0001) and evening vs night (MD = 0.38, 95% CI 0.33-0.42, P = .002). No significant difference in median PPI between AECOPD and surgical patients was found (MD = 0.15, 95% CI −0.08-0.38, P = .62). Conclusion:Lower PPI during daytime vs evening and night-time were seen for both populations. The highest frequency of serious adverse events and mortality was seen among patients with low median PPI. The clinical impact of PPI monitoring needs further confirmation. How to cite this article: Rasmussen PS, Aasvang EK, Olsen RM, et al. Continuous peripheral perfusion index in patients admitted to hospital wards -An observational study. Acta

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Surgical stress response and the potential role of preoperative glucocorticoids on post-anesthesia care unit recovery

Cited by 33 publications

References 0 publications

High‐dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double‐blinded randomized clinical trial substudy

High‐dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double‐blinded randomized clinical trial substudy

On the generalizability of same-day partial knee replacement surgery—A non-selective interventional study evaluating efficacy, patient satisfaction, and safety in a public hospital setting

Continuous peripheral perfusion index in patients admitted to hospital wards – An observational study

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